Demographic Data - Nursing Crib
Demographic Data
| | |
|Name |Lumasac, Francis Llanita |
|Address |Brgy. Pingit, Baler, Aurora |
|Age |21 years old |
|Sex |Male |
|Date of Birth |February 26, 1985 |
|Place of Birth |Baler, Aurora |
|Nationality |Filipino |
|Religion |Roman Catholic |
|Civil Status |Single |
|Occupation |Construction Worker |
| | |
|Father |Domingo Lumasac |
|Occupation |Deceased |
| | |
|Mother |Clarita Llanita |
|Occupation |Housekeeper |
Physical Assessment & General Appearance
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|MEASUREMENTS |FINDINGS |
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|Weight |57 kg |
|Height |171 cm |
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|Level of Consciousness |◊ Spontaneous, |
| |oriented |
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|Body Build |◊ Medium |
|Posture & Gait |◊ Erectposture, |
| |active |
| |purposeful |
| |stride |
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|Overall hygiene & |◊ Good |
|Grooming | |
Head to Toe Assessment
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|BODY PART |TECHNIQUE USED |FINDINGS |INTERPRETATION |
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|◊ HEAD | | | |
|Skull |◊ palpation |◊ proportional to the size of the|◊ Normal |
| | |body, round, with prominences in | |
| | |the frontal area anteriorly & the| |
| | |occipital area posteriorly, | |
| | |symmetrical in all planes, gently| |
| | |curved | |
| | | | |
| | |◊ scalp is white, clean, free | |
| | |from masses, lumps, nits, | |
| | |dandruff & lesions, with no areas| |
| | |of tenderness upon palpation; | |
| | |hair is black, evenly distributed| |
|Scalp/ Hair |◊ inspection |& covers the whole scalp, thick &|◊ Normal |
| |◊ palpation |shiny | |
| | | | |
| | |◊ oblong shaped, symmetrical, | |
| | |smooth & no involuntary muscle | |
| | |movements | |
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| | |◊ eyes are parallel & evenly | |
| | |placed, symmetrical, | |
| | |non-protruding, with scant amount| |
| | |of secretions, both eyes black & | |
| | |clear; sclera is white & clear; | |
| | |eyebrows are black, symmetrical, | |
| | |thick, can raise both | |
|Face |◊ inspection |symmetrically & without |◊ Normal |
| | |difficulty, evenly distributed & | |
| | |parallel with each other; | |
| | |eyelashes are evenly distributed | |
| | |& turned outward; upper eyelids | |
| | |cover a small portion of the | |
|Eyes/ Vision |◊ inspection |iris, cornea & the sclera when |◊ Normal |
| |◊ palpation |the eyes are open, when the eyes | |
| | |are closed the lids meet | |
| | |completely, symmetrical & the | |
| | |color is the same as the | |
| | |surrounding skin; lid margins are| |
| | |clear, without scaling or | |
| | |secretions; lower palpebral | |
| | |conjunctiva are shiny, moist, | |
| | |transparent & salmon pink in | |
| | |color; iris are proportional to | |
| | |the size of the eye, round & | |
| | |symmetrical; pupils are from | |
| | |pinpoint to almost the size of | |
| | |the iris, round, symmetrical, | |
| | |constricts with increasing light | |
| | |& accommodation; able to move | |
| | |eyes in full range of direction | |
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| | |◊ ears are parallel, symmetrical,| |
| | |proportional to the size of the | |
| | |head, bean-shaped, helix is in | |
| | |line with the outer canthus of | |
| | |the eye, skin is the same color | |
| | |as the surrounding area & clean; | |
| | |ear canal is pinkish, clean, with| |
| | |scant amount of cerumen & a few | |
| | |cilia; able to hear whisper | |
| | |spoken 2 feet away; 2 piercing | |
| | |are found in left ear and 1 | |
| | |piercing in right ear | |
| | | | |
| | |◊ nose is in midline, | |
| | |symmetrical, patent; internal | |
| | |nares are clean, dark pink with | |
| | |few cilia | |
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| | |◊ lips are dark pink, | |
| | |symmetrical, lip margin is | |
| | |well-defined, smooth & moist; | |
| | |gums are dark pink, smooth, | |
| | |moist, no swelling, no | |
| | |retraction, no discharge; 32 | |
| | |teeth are present, aligned, with | |
| | |no dental caries; tongue is | |
| | |pinkish, slightly rough on top, | |
| | |smooth along the lateral margins,| |
| | |moist, shiny & freely movable; | |
| | |cheeks are pinkish, moist & | |
| | |smooth; frenulum is in midline, | |
| | |straight & thin; soft palate is | |
| | |pinkish, smooth & moist; hard | |
| | |palate is slightly pinkish; uvula| |
| | |is at the center, symmetrical & | |
| | |freely movable | |
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| | |◊ proportional to the size of the| |
| | |body & head, symmetrical & | |
| | |straight, no palpable lumps, | |
|Ears/ Hearing |◊ inspection |masses or areas of tenderness |◊ Normal |
| |◊ palpation | | |
| | |◊ chest contour is symmetrical, | |
| | |spine is straight, no lumps, no | |
| | |masses, no tender areas, with | |
| | |clear breath sounds; a circular | |
| | |scar is found in his right upper | |
| | |abdomen | |
| | | | |
| | |◊ no abnormal pulsations, | |
| | |pulsations are palpable & visible| |
| | |in apical area | |
| | | | |
| | |◊ symmetrical, dark pink nipples,| |
| | |no cracks & discharges, uniform | |
| | |in skin color, smooth & intact, | |
| | |no lumps, masses & tenderness | |
| | | | |
| | |◊ abdominal skin is unblemished, | |
| | |no scars, color is uniform with | |
| | |the body color, abdomen is | |
| | |rounded with symmetric movements | |
| | |caused by respiration; umbilicus | |
| | |is concave | |
|Nose |◊ inspection | |◊ Normal |
| |◊ palpation |◊ symmetrical, with visible | |
| | |veins, fine hair evenly | |
| | |distributed, warm, dry & elastic | |
| | |upon palpation, with area of | |
| | |tenderness on the left arm; palms| |
| | |are pinkish, warm, soft & | |
| | |elastic; nails are transparent, | |
|Mouth/ Lips |◊ inspection |smooth & convex with light pink |◊ Normal |
| |◊ palpation |nail beds & white translucent | |
| | |tips; 5 fingers in each hand; | |
| | |both shoulders, arms, elbows, | |
| | |hands & wrists can be moved in | |
| | |different range of motion with | |
| | |relative ease; left wrist with | |
| | |tattoo; scars on the left arm | |
| | | | |
| | |◊ skin is smooth, fine hair is | |
| | |evenly distributed, absence of | |
| | |varicose veins, muscles | |
| | |symmetrical, length symmetrical, | |
| | |5 toes in each foot, sole & | |
| | |dorsal surface is smooth with | |
| | |pink nail beds & white | |
| | |translucent tips; right leg, | |
| | |knee, ankle, & toe can be moved | |
| | |in different range of motion with| |
| | |relative ease; scar on both | |
| | |patellar; scar on right sural; | |
| | |with external fixator on left | |
| | |crural. | |
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|◊ NECK |◊ inspection | |◊ Normal |
| |◊ palpation | | |
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|◊ THORAX & LUNGS |◊ inspection | |◊ Normal |
| |◊ palpation | | |
| |◊ percussion | | |
| |◊ auscultation | | |
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|◊ HEART | | | |
| |◊ inspection | |◊ Normal |
| |◊ palpation | | |
| |◊ percussion | | |
| |◊ auscultation | | |
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|◊ BREAST | | | |
| |◊ inspection | |◊ Normal |
| |◊ palpation | | |
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|◊ ABDOMEN | | | |
| |◊ inspection | |◊ Normal |
| |◊ auscultation | | |
| |◊ percussion | | |
| |◊ palpation | | |
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|◊ UPPER EXTREMITIES | | | |
| |◊ inspection | |◊ Normal |
| |◊ palpation | | |
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|◊ LOWER EXTREMITIES | | | |
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| |◊ inspection | |◊ Deviated |
| |◊ palpation | | |
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