General Santos Doctors’ Medical School Foundation, Inc.

Bulaong Subd., Brgy. West, General Santos City, Philippines

Telephone Nos. (083) 552-9793 | [email protected]

Area: Baranggay Mabuhay Inclusive Dates: November 7, 2022

*Students Name: Galido, Crystal Jade R.

Rojo, Claire Aniza
Year and Section: BSN-2B
Group: Group 4
BIOGRAPHICAL DATA

Patients Full Name: Boy T.Y Marital Status:_Single___________________ Immunization: BCG, Hepatitis B, Pentavalent _
Age and Sex: 3 years old - male Educational Level: N/A Vaccine, & Oral Polio Vaccine
Birthdate: September 06, 2019 Occupation: None Allergies: None _
Religion: Roman Catholic Recent Travel: None Medications: None _
Chief complaints: None
_____________________________________
Family Health History: History of Past Illness (Childhood illness/ History of Present Illness:
None Hospitalization/ Surgeries/ Injuries/ Chronic Ear Serumen drainage
Illness): Serumen drainage on ears especially
when he is sick

CEPHALOCAUDAL PHYSICAL ASSESSMENT

GENERAL APPEARANCE:

Vital Signs:
Temp: 35.9C PR: 7 5bpm RR: 19 bpm

Interpretation:
The normal temperature range is 36.5°C–37.5°C. The client's temperature is below the normal range. The pulse rate is within the normal range of 60-100 beats per
minute. The respiratory rate is within the normal range of 12–20 breaths per minute.
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines
Telephone Nos. (083) 552-9793 | [email protected]

Inspection Palpation Percussion Auscultation Interpretation

Skin Skin is unblemished and Smooth and not dry skin Not assessed Not assessed Skin is smooth which is normal for younger
no presence of any foul texture people because of the sebum production and
odor. not dry that may indicate hypothyroidism.
(Weber et.al, Health Assessment in Nursing
6th edition 2022)

No presence of foul odor of of perspiration

that may indicate disorder of sweat glands or
poor hygiene practices. (Weber et.al, Health
Assessment in Nursing 6th edition 2022)
Uniform skin color Skin is warm upon No abnormal skin coloration related to
throughout the body and palpation oxygen deficiency, hepatic dysfunction, or
skin is intact. diabetes mellitus. Skin temperature is normal
which indicates no signs of hypothermia and
hyperthermia. (Weber et.al, Health
Assessment in Nursing 6th edition 2022)
Good skin turgor (Skin Skin also has good turgor which means client
springs back to previous is well hydrated. (Weber et.al, Health
state after less than 2 Assessment in Nursing 6th edition 2022)
seconds when pinched).
Hair The hair in the head is No presence of Not assessed Not assessed No signs of patches of hair loss (alopecia)
evenly distributed, thin in tenderness, masses, that may indicate stress, infection, and
volume, and straight. lesions in scalp. nutritional deficiencies. No raised lesions or
masses that may indicate infections or tumor
growth. (Weber et.al, Health Assessment in
Nursing 6th edition 2022)
The hair color in the head Scalp is clean, dry, and Excessive scaliness is not present that may
is black. no presence of dandruff. indicate dermatitis. (Weber et.al, Health
Assessment in Nursing 6th edition 2022)
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines
Telephone Nos. (083) 552-9793 | [email protected]

Nails No presence of Good capillary refill. Not assessed Not assessed No presence of nail changes such as
discoloration. discoloration that may indicate malnutrition,
or bacterial infection. Prompt return of
pinkish color means that the client is well
dehydrated and there is enough blood flow to
tissues. (Weber et.al, Health Assessment in
Nursing 6th edition 2022)
Even nail cuts. Nails are hard, smooth, Client has good personal hygiene. No
and nail plate is firmly presence of improper nail- cutting technique
attached to nail bed. that can lead to ingrown nails or infection No
presence of thickened nails and
inflammation that may indicate a decrease in
circulation and local infection. (Weber et.al,
Health Assessment in Nursing 6th edition
2022)
There is no sign of No sign of inflammation or separation of the
inflammation or nail plate from the nail bed that may indicate
separation of the nail yeast infection. (Weber et.al, Health
plate from the nail bed. Assessment in Nursing 6th edition 2022)
Head Head is normocephalic No presence of lesions, Not assessed Not assessed The head is normal. It is normocephalic and
and facial features are masses, and tenderness. symmetric. (Berman et.al, Fundamentals of
symmetric. Nursing 11th edition)
Head is normally hard and there is absence
of lesions or masses that may indicate recent
trauma or a sign of cancer. (Weber et.al,
Health Assessment in Nursing 6th edition
2022)
Symmetrical facial No presence of unsual facial movements that
movement, palpebral may indicate neurologic problem or organic
fissures equal in size, and disease. No presence of drooping on one side
of face that may indicate neurologic
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines
Telephone Nos. (083) 552-9793 | [email protected]

symmetric nasolabial condition such as Bell palsy. (Weber et.al,

folds. Health Assessment in Nursing 6th edition
2022)
Eyes Eyes are equal, Not assessed Not assessed Not assessed The patient shows no signs of Eye protrusion
symmetrical and round. and has normal Eyeball shape. (Weber et.al,
Health Assessment in Nursing 6th edition
2022)
No presence of swelling No presence of swelling or redness of the eye
or redness of the eye. No that may indicate allergy, bacterial or viral
presence of eye infection. No eye discharge other than tears
discharge. that may indicate bacterial or viral infection.
(Weber et.al, Health Assessment in Nursing
6th edition 2022)
PERRLA The pupil shape and size are normal and eye
Pupils equally rounded movement is smooth and symmetric
and reactive to light and throughout all 6 directions. There is no
accommodation. abnormal movements that may indicates a
weakness in one or more extraocular muscles
Pupils constrict at near or dysfunction of the cranial nerve that
objects and dilates at far innervates the particular muscle. (Weber
objects. et.al, Health Assessment in Nursing 6th
edition 2022)
Six cardinal movement is
good.
Ears The ears are symmetrical, No presence of Not assessed Not assessed The ears are equal bilaterally, normally (4-10
equal in size, and in tenderness, lesions, cm in size). Earlobes are attached as
proportion to the head. swelling, nodules, and expected to Asians. No presence of
pain. tenderness, lesions, swelling, nodules, and
pain that may indicate postauricular cyst,
mastoiditis, or otitis media. (Weber et.al,
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines
Telephone Nos. (083) 552-9793 | [email protected]

Health Assessment in Nursing 6th edition

2022)
The color matches the The pinna recoils when Ears are normal. The color of the ears is the
color of the face and no folded. same as facial skin, it is symmetrical, mobile,
presence of foreign firm, and not tender (Berman et.al,
bodies. Fundamentals of Nursing 11th edition)
Presence of ear drainage. Presence of ear drainage that may indicates
infection. (Weber et.al, Health Assessment
in Nursing 6th edition 2022)
Nose Nose color is consistent to No presence of Not assessed Not assessed Nose is symmetrical to the face which is
the facial color. Nasal tenderness and lesions. normal and no deviated septum that may
septum is in the midline. appear to be an overgrowth of tissue. (Weber
et.al, Health Assessment in Nursing 6th
edition 2022)
No presence of mucous No presence of mucous drainage that may
drainage. indicate allergy, sinus infection or
cerebrospinal fluid leak. (Weber et.al, Health
Assessment in Nursing 6th edition 2022)
No nasal flaring. Nasal flaring is seen with labored
respirations and is indicative of hypoxia.
(Weber et.al, Health Assessment in Nursing
6th edition 2022)
Mouth and Throat The lips are pink, moist, Not assessed Not assessed Not assessed No pallor seen on the lips that indicate
symmetric with smooth anemia or shock. Bluish or cyanotic lips are
texture, and not swelling. absent that may result from cold or hypoxia.
No swelling of lips that may indicate allergy.
(Weber et.al, Health Assessment in Nursing
6th edition 2022)
Presence of tooth decay in Tooth decay is caused by bacteria and other
upper and lower molars. things. It can happen when foods containing
sugars and starches are left on the teeth. Such
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines
Telephone Nos. (083) 552-9793 | [email protected]

No presence of upper foods include milk, soda, raisins, candy,

central incisor. cake, fruit juices, cereals, and
bread. (Hopkinsmedicine 2019)
Neck The head is centered and Trachea and thyroid Not assessed Not assessed Neck is symmetric with the head centered
the neck is symmetrical gland is positioned in without bulging masses that may indicate
without any protruding the midline. enlarged thyroid gland or tumor. (Weber
masses. et.al, Health Assessment in Nursing 6th
edition 2022)
No presence of lesions No tenderness and Skin condition is good around the neck and
around the neck. swelling in the lymph no tenderness in the lymph nodes that may
nodes. indicate inflammation. (Weber et.al, Health
Assessment in Nursing 6th edition 2022)
No signs of pain during There is no pain with active ROM, the test is
ROM inspection. deemed negative, and the client does not
have a strain or sprain. Active ROM is
considered a "screening assessment test"
because it will show positive with either
muscle strain or ligament sprain.
(Muscolino, J., 2017)
There is no presence of Jugular vein distention is a sign of increased
jugular vein distension. pressure inside the vena cava. It can be the
sign of a severe condition, including heart
failure (Cadman, 2017).
Thorax and Back Scapulae and shoulders Fremitus is symmetric Not assessed Normal breath sounds No scoliosis noted and no unequal fremitus
(cardio-pulmonary) are symmetrical and are at and easily identifiable. without dyspnea. which usually results from bronchial
equal horizontal obstruction or emphysema. (Weber et.al,
positions. Health Assessment in Nursing 6th edition
2022)
Spine appears straight and No tenderness, masses, No presence of kyphotic spine that indicates
thorax appears or pain upon palpation. a loss of lung resiliency and a loss of skeletal
symmetric. muscle. Tenderness or pain may indicate
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines
Telephone Nos. (083) 552-9793 | [email protected]

muscle soreness from recent exercise.

(Weber et.al, Health Assessment in Nursing
6th edition 2022)
Breast No presence of any Not assessed Not assessed Not assessed No presence of any discharge that may
discharge. indicate infections. (Weber et.al, Health
Assessment in Nursing 6th edition 2022)
Abdomen It is unblemished skin and Not assessed Not assessed Not assessed No abnormal skin coloration related to
is uniform in color. oxygen deficiency, hepatic dysfunction, or
diabetes mellitus. (Weber et.al, Health
Assessment in Nursing 6th edition 2022)
Genito-Urinary There were no pain or Not assessed Not assessed Not assessed No presence of pain or discomfort during
discomfort felt in urination that may indicate urinary tract
urinating. infection. (Weber et.al, Health Assessment
in Nursing 6th edition 2022)
Musculoskeletal/Extre Able to maintain balance Not assessed Not assessed Not assessed Presence of good balance and normal gait
mities when walking with while walking indicate good gait. (Weber
opposite-swinging hands. et.al, Health Assessment in Nursing 6th
edition 2022)
ROM is good. Able to The client can flex, extend, adduct, and
perform flexion, abduct. There is no pain with active ROM,
extension, abduction, and the test is deemed negative, and the client
adduction normally. No does not have a strain or sprain. Active ROM
signs of pain in doing is considered a "screening assessment test"
ROM. because it will show positive with either
muscle strain or ligament sprain.
(Muscolino, J., 2017)
There were no signs or No presence of bulging or swelling that may
presence of bulging or indicate rheumatoid arthritis or fluid. (Weber
swelling on the upper and et.al, Health Assessment in Nursing 6th
lower extremities. edition 2022)
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines
Telephone Nos. (083) 552-9793 | [email protected]

References:

Berman, A., Snyder, S., & Frandsen, G. (2021). Kozier and Erb's fundamentals of nursing: Concepts, process, and Practice.

Weber, J., & Kelley, J. (2022). Health Assessment in Nursing. Wolters Kluwer.

Cadman, B. (2017, December 16). What to know about jugular vein distention (JVD). MedicalNewsToday. https://www.medicalnewstoday.com/articles/320320

Muscolino, J. (2017, October 16). Neck general orthopedic assessment: Range of motion and manual resistance. Learn Muscles. Retrieved October 19, 2022, from
https://learnmuscles.com/blog/2017/08/14/general-orthopedic-assessment-range-motion-manual-resistance-assessment-
neck/?fbclid=IwAR1_5M4kQL8oGnexLT1e6GrhqS_vcZjXbeT7IP0nsxLpkfHCvk4yJGDggAQ#:~:text=Active%20ROM%20assessment%20is%20performed%20by%20as
king%20the,the%20client%E2%80%99s%20neck%20through%20a%20ROM%20%28Fig.%202B%29

Achieve Physiotherapy. (2020, January 10). Physiotherapy for leg weakness during pregnancy. Retrieved October 19, 2022, from
https://achievephysiotherapy.co.uk/physiotherapy-for-leg-weakness-during-
pregnancy/#:~:text=Leg%20weakness%20is%20often%20a,legs%20while%20they%20are%20pregnant.

Lamppa, J. A. (2022, July 22). Vulvar varicosities during pregnancy: What can you do? Mayo Clinic. Retrieved October 19, 2022, from https://www.mayoclinic.org/healthy-
lifestyle/pregnancy-week-by-week/expert-answers/vulvar-varicosities-during-pregnancy/faq-
20419426#:~:text=Vulvar%20varicosities%20are%20varicose%20veins,the%20pelvic%20region%20during%20pregnancy.

Tooth decay (caries or cavities) in children. Tooth Decay (Caries or Cavities) in Children | Johns Hopkins Medicine. (2019, November 19). Retrieved November 16, 2022, from
https://www.hopkinsmedicine.org/health/conditions-and-diseases/tooth-decay-caries-or-cavities-in-
children#:~:text=What%20causes%20tooth%20decay%20in,juices%2C%20cereals%2C%20and%20bread.