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Pinky Assessment Part2

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  II. Assessment ã PHYSICAL ASSESSMENTGeneral Survey Received lying on bed conscious, responsive and coherent. Fairly groomed. Withclean and intact top dressing at right lower quadrant. With IVF #4 ! $ in%using well at the right dorsal metacarpal vein regulated at &' gtts(min. )n !). *apillary re%ill o% + sec. Vital Signs ate hi%t-ime*RRRR-emp.'/0+/0&10&23''am2222+(2&&1.4+3''pm'+&'(2'&1.' 5in ã rown s5in generally uni%orm in color in areas e6cept in areas e6posed in the sun ã !o 7aundice ã !ormal capillary re%ill time +sec.8ead ã !o head and scalp lessions ã ymmetric %acial %eatures and movements ã ymmetric nasolabial %olds ã 9venly distributed blac5 hair  ã !o in%estations9yes  ã 9yebrows symmetrical with equal movement ã 9yelashes equally distributed and curled slightly outward ã 5in o% eyelids intact with no discoloration ã 9yelids close symmetrically ã ilateral blin5ing e6hibited ã !o discharges ã lightly in pale palpebral con7unctiva ã Iris blac5 in color  ã upils equals in si:e with smooth borders ã Illuminated pupils constricts ã upils converge when near ob7ect is moved toward the nose ã When loo5ing straight ahead, the client can see ob7ects in the periphery ã oth eyes coordinated, move in unison with parallel alignment9ars ã *olor same as %acial s5in ã ymmetrically aligned ã inna immediately recoils a%ter it is %olded ã inna is not tender  ã !o lesions or discoloration ã !ormal voice tones audible ã  ;ble to hear tic5ing o% a watch in both ears  !ose ã ymmetric and straight ã !asal septum intact and in the midline<outh and throat ã )uter lips uni%orm slightly pale in color with symmetric contour  ã uccal mucosa is o% uni%orm slightly pale in color ã =ums are slightly pale ã -ongue slightly pin5ish, not so moist, at central position!ec5 ã !o tenderness ã ymmetrical nec5*hest ã Firm ã !o tenderness ã =enerally symmetric in si:e*ardiovascular  ã  +(2& ã R 22 ã ymmetric pulse strengthRespiratory(*hest ã *hest symmetric  ã *hest wall intact, no tenderness, no masses ã ymmetric chest e6pansion and e6cursion ã 9ndothelin0converting 9n:yme 9*9, >?@ crac5les, >?@ whee:es ã Respiratory rate 2=astrointestinal(;bdomen ã =lobular ã !ormoactive bowel sounds ã !o splenomegaly ã !o hepatomegaly ã o%t ã -ympanic ã !o tenderness=enitoArinary ã !o tenderness when urinating<usculos5eletal(96tremities ã <uscle equal si:e on both sides o% the body ã !o tenderness ã mooth coordinated movements!eurologic ã *an respond to verbal commands ã )riented
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