CHECK OFF SHEET SKIN
CHECK OFF SHEET FULL
There’s a full and symmetric expansion and the thumbs separate 2-3 cm during deep inspiration when assessing for the respiratory excursion. Lungs / Chest: The chest wall is intact with no tenderness and masses.The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible.The trachea is placed in the midline of the neck.The lymph nodes of the client are not palpable.The client showed coordinated, smooth head movement with no discomfort. The uvula of the client is positioned in the midline of the soft palate.The smooth palates are light pink and smooth while the hard palate has a more irregular texture.There is a presence of thin whitish coating. It is pink in color, moist and slightly rough. The tongue of the client is centrally positioned.The buccal mucosa of the client appeared as uniformly pink moist, soft, glistening and with elastic texture.Teeth and Gums: There are no discoloration of the enamels, no retraction of gums, pinkish in color of gums.The client was able to purse his lips when asked to whistle.
The lips of the client are uniformly pink moist, symmetric and have a smooth texture.When lightly palpated, there were no tenderness and lesions There was no presence of discharge or flaring. Nose: The nose appeared symmetric, straight and uniform in color.During the assessment of Watch tick test, the client was able to hear ticking in both ears. When palpating for the texture, the auricles are mobile, firm and not tender. The auricles are aligned with the outer canthus of eye. Ears: The Auricles are symmetrical and has the same color with his facial skin.The client was able to read the newsprint held at a distance of 14 inches.When testing for the Extraocular Muscle, both eyes of the client coordinately moved in unison with parallel alignment.When assessing the peripheral visual field, the client can see objects in the periphery when looking straight ahead.Pupils converge when object is moved towards the nose. Pupils constrict when looking at near object and dilate at far object. PERRLA (pupils equally round respond to light accommodation), illuminated and non-illuminated pupils constricts. The pupils of the eyes are black and equal in size.The client blinks when the cornea was touched. Cornea is transparent, smooth and shiny and the details of the iris are visible.There is no edema or tearing of the lacrimal gland.The palpebral conjunctiva appeared shiny, smooth and pink.The Bulbar conjunctiva appeared transparent with few capillaries evident.Eyelids: There were no presence of discharges, no discoloration and lids close symmetrically with involuntary blinks approximately 15-20 times per minute.Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward.The client’s eyebrows are symmetrically aligned and showed equal movement when asked to raise and lower eyebrows. Face: The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses.Skull: There are no nodules or masses and depressions when palpated.Head: The head of the client is rounded normocephalic and symmetrical.When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds. It is smooth and is intact with the epidermis. Nails: The client has a light brown nails and has the shape of convex curve.There are also no signs of infection and infestation observed. Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair.He has a good skin turgor and skin’s temperature is within normal limit.
Skin: The client’s skin is uniform in color, unblemished and no presence of any foul odor.SEE ALSO: Nursing Health Assessment Mnemonics & Tips
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